Basic Information
| Provider Information | |||||||||
| NPI: | 1437557220 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHORE HEALTH SYSTEM, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SHORE BEHAVORIAL SUBSTANCE ABUSE IOP | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 219 S WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | EASTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216012913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108221000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 219 S WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | EASTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216012913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108221000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2014 | ||||||||
| LastUpdateDate: | 02/10/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KOZEL | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 4108221000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UNIVERSITY OF MARYLAND SHORE REGIONAL HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | 423225900 | 05 | MD | MEDICAID |